When changing regimens after first– or multiple–regimen failure, consider the stage of HIV, nadir and current CD4 cell count, comorbidities, treatment history, current and previous drug resistance tests, and drug interactions.

Include at least two drugs, and preferably three fully active drugs or drugs from new classes.

Single–agent switches to decrease toxicity, avoid drug interactions, or improve convenience and adherence are possible, provided the potency of the regimen is maintained and drug interactions are managed.

Boosted protease inhibitor monotherapy is not recommended, except when other drugs raise issues of toxicity or tolerability.

Delaying such switches may affect adherence and risk development of resistance.

The 10th Perfect Health Mela organized by the Heart Care Foundation of India in 2003 was based on the theme ATTENtion, Hypertension and Safe syringe practices. In the photo: Mr Romesh Bhandari, Ex-governor of Goa, Padma Shri and Dr B C Roy National awardee Dr K K Aggarwal, President HCFI.

IMSA Update

International Medical Science Academy (IMSA) Update

Parasitological measures of artemisinin susceptibility

Artemisinin resistance is highly unlikely if the proportion of patients with parasite density <100,000 parasites/microL following a 3–day course of therapy with an artemisinin combination regimen is <3 %.

COURT RESTRAINS Election Commission to permit candidates to contest IMA Elections who have paid their nomination fee by cheque till next date

The Election Commission on 6th August 2010, issued a notification vide No.IMA/EC/2010/19 under the signatures of Dr. P. Vijaya Chander Reddy, Chief Election Commissioner, informing the candidates of the receipt of their nomination and to deposit their nomination fee and consent for the post for which their name was nominated. The relevant part that pertains to the mode of payment of Nomination fee by every candidate, which reads as under: " The last date for receipt of consent/withdrawal along with nomination fee by Demand Draft in the name of 'Indian Medical Association', payable at New Delhi as mentioned above is 31st August, 2010 by 5.00 p.m." This is for your information and necessary action.” While all candidates deposited their nomination fee by Demand Drafts, the following deposited their nomination fees by cheque: Dr Vinay Aggarwal candidate for President Elect 2010-11; Dr. Dharam Prakash candidate for National Vice President Elect2010-11; Dr D.R. Rai candidate for Hony. Secretary General 2010-12; Dr V.K. Narang candidate for Hony. Finance Secretary; Dr Ajay Gambhir, Dr. H.R.Satija, Dr. R.N. Tandon; All 3 as candidates for Hony. Joint Secretary 2010-12; Dr Atul Arora, Dr Ravi Mallick candidates for Hony. Asst. Secretary 2010-12 and Dr Anil Bansal candidate for Hony. Joint Finance Secretary (Delhi). A complaint was lodged with the Election commission to cancel the nominations of the above candidates as they had deposited cheques in direct contravention to the notification issued by the EC.
Dr Premanand Ambali approached a court of law in Bijapur, Karnataka and filed a case against the Election Commission. The Hon'ble Court directs as under: Issue ad interim exparte Temporary Injunction restraining the Defendant from permitting the candidates to contest IMA Elections who have paid their nomination fee by cheque till next date.

Despite 59% drop, India tops maternal mortality list

Though India has seen a dramatic fall in maternal mortality rate (MMR) by 59% between 1990 and 2008, the country is still home to the highest number of women dying during childbirth across the world. India's MMR stood at 570 in 1990, which fell to 470 per 100,000 live births in 1995, 390 in 2000, 280 in 2005 and 230 in 2008. India, which has seen an annual decrease of MMR by 4.9% since 1990, now records 63,000 maternal deaths a year. For instance, the lifetime risk of maternal death (the probability that a 15-year-old female will die eventually from a maternal cause) is 1 in 140 - inarguably a shamefully high figure. According to the latest report, "Trends in Maternal Mortality", released jointly by WHO, UNICEF, UNFPA and World Bank, just days before Who's Who of the Planet meet at New York for the all-important Millennium Development Goals (MDG) meeting, the number of women dying due to complications during pregnancy and childbirth has decreased by 34% from an estimated 5.46 lakhs in 1990 to 3.58 lakhs in 2008. Even though the progress is notable, the annual rate of decline is less than half of what is needed to achieve the MDG target of reducing the MMR by 75% between 1990 and 2015. (Source: The Times of India)

International News

(Dr Monica and Brahm vasudev)

Low–carb diets heavy on meat may raise health risks

A low–carbohydrate diet that obtains its fats and proteins from vegetable sources rather than meats is in all probability healthier. A comparison of the two diets for over two decades showed that the low–carb, vegetable–based plan resulted in reduced rates of death from cardiovascular disease and cancer, and a lower rate of all–cause death overall. The study is published in the Sept. 7 issue of the Annals of Internal Medicine)

First prototype model of artificial kidney

Researchers at the University of California-San Francisco have unveiled the first prototype model of an artificial kidney device. The device relies on the blood pressure of the body to perform filtration without needing pumps or an electrical power supply. They have established the feasibility of an implantable model in animal models and anticipate clinical trials in 5 to 7 years.

Better personalize treatment for high blood pressure

Some drug combinations work better for certain populations and raises the possibility that measuring blood levels of rennin might help optimize care in some people.

Increased levels of cortisol in the hair shaft may increase risk of heart attack

According to a study published online in the journal Stress, increased levels of the stress hormone cortisol in the hair shaft may increase the risk of heart attack.

Couples are generally advised to visit a gynecologist if they do not conceive after a year of unprotected intercourse. It also depends on the age. The doctor will assess what could be causative factor and guide the couple accordingly. The initial tests include a semen analysis, a few blood tests to assess for ovulation and the Tubal patency Test (HSG).

What are the causes of infertility in men?

Male infertility could be erectile problems or problem in the sperm count. The causes of sperm production problems can exist from birth or develop later as a result of severe medical illnesses, including mumps and some sexually transmitted diseases, or from a severe testicle injury, tumor, or other problem. Inability to ejaculate normally can prevent conception, too, and can be caused by many factors, including diabetes, surgery of the prostate gland or urethra, blood pressure medication, or impotence.

Obstetrics Update: Question of the Day

Can Ultrasonography produce major anatomic malformations in the fetus? (Dr Sujata Kanhere)

Diagnostic ultrasonography is routinely performed in pregnant women. The Food and Drug Administration (USA) has expressed concerns about the safety of this procedure. Very high intensity ultrasound can have biologic effects in experimental animals. (Baker ML, et al. Biological effects of diagnostic ultrasound. A review. Radiology 1978;126:479). Whether these changes apply to human tissue cells is not known. Furthermore, even assuming there is small biologic risk from ultrasound, the benefits far outweigh any such risk.

Hawley Harvey Crippen was hanged to death in London in one of the most notorious and famous murder cases in British history for the murder of his wife Cora Henrietta Crippenin, on 23 November 1910 on the basis of forensic evidence. For nearly a century, Crippen, a doctor, was thought to have poisoned his wife with an obscure toxin, and buried. He was labeled "one of the most dangerous and remarkable men who have lived in this century." Researchers have now cast doubts on this conviction. Now forensic science at Michigan State University is producing evidence that his execution was a mistake. David Foran, a forensic expert and director of MSU’s forensic science program, partnering with clinical and forensic toxicologist John Harris Trestrail the managing director of the regional poison center in Grand Rapids, is combining state–of–the–art DNA analysis with solid sleuthing to show the remains buried in Crippen’s basement couldn’t have been his wife.

Medi Finance Update

Gift Tax

A woman can receive gifts from anyone except her husband, mother–in–law and father–in–law.

Drug Update

Drugs prohibited for manufacture, sale and distribution from subsequent date

Drug Formulation

Effective date

Notification

Fixed dose combination of Nalidixic Acid with any anti–amoebic including Metronidazole.

Jan 1, 2002

GSR 170(E)
dt.12.3.01

Lab Update

Prostate specific antigen (PSA)

Prostate biopsy may elevate PSA levels by a median of 7.9 ng/mL within 4 to 24 hours following the procedure. Levels will remain elevated for 2 to 4 weeks.

IJCP Special

Dr Good Dr Bad

Situation: A patient came with first–onset atrial fibrillation.Dr Bad: Get an Echo done.Dr Good: Also get T3 T4 and TSH done. Lesson: Subclinical hyperthyroidism is also associated with an increased risk of atrial fibrillation. (N Engl J Med 1994; 331:1249)

Make Sure

Situation: A patient after receiving 40 units of insulin developed severe hypoglycemia.Reaction: Oh My God! The order was for 4 units. Lesson: Make sure that 4 unit is not written as 4.0 units.

Quote of the Day

Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship. - Buddha (Contributed by Dr. G.M. Singh)

Hypertension Alert

Hypertensive urgency

There is no proven benefit from rapid reduction of the blood pressure in patients with severe asymptomatic hypertension, and myocardial or cerebral ischemia can be precipitated by overly rapid blood pressure lowering.

eQuiz

Read this…………………

What 15-letter word contains the letter 'E' five times and no other vowels?

The answer for yesterday’s eQuiz : "The correct answer is B"Explanation: The most likely scenario is that this octogenarian developed a urinary tract infection with acute delirium. She was unable to access fluids over the next several hours and developed hypovolemic hypernatremia. Her free water deficit is as follows: Total body water × (Current serum sodium/140 – 1). Total body water is 0.6 × wt in kg for adult male and 0.5 × wt in kg for an adult female. For elderly patients, it is 0.5 × wt in kg for males and 0.45 × wt in kg for females. Thus this patient’s total body water is 0.45 × 60 = 26 liters. Her free water deficit is 26 × (160/140 – 1) = 4.3 liters. The ideal rate of correction of hypernatremia is 0.5 mEq/l/hr and 10 – 12 mEq/l/day. Too rapid correction with free water can have adverse outcomes. Half normal saline is the best fluid for adequate replacement and D5 may cause too rapid correction. 0.9% NaCl will help volume depletion but may worsen hyperchloremic acidosis. Sodium bicarbonate would be useful if patient had significant acidosis. It is important to check electrolytes frequently.

General Equations & Statistics
A successful man is one who makes more money than his wife can spend.
A successful woman is one who can find such a man.(Contributed by Dr Dewat Ram Nakipuria)

Funny one liner

Santa in an antique shop, 'Do you have anything new?'

An Inspirational Story

The RockAn old farmer had plowed around a large rock in one of his fields for years. He had broken several plowshares and a cultivator on it and had grown rather morbid about the rock.
After breaking another plowshare one day, and remembering all the trouble the rock had caused him through the years, he finally decided to do something about it.

When he put the crowbar under the rock, he was surprised to discover that it was only about six inches thick and that he could break it up easily with a sledgehammer. As he was carting the pieces away he had to smile, remembering all the trouble that the rock had caused him over the years and how easy it would have been to ged rid of it sooner.

Readers Responses

One song can spark a moment, One flower can wake the dream.
One tree can start a forest, One bird can herald spring.
One smile begins a friendship, One handclasp lifts a soul.
One star can guide a ship at sea, One word can frame the goal.
One vote can change a nation, One sunbeam can light a room.
One candle can wipe out darkness, One laugh will conquer gloom.
One step must start each journey, One word must start each prayer.
One hope will raise our spirits, One touch can show you care.
One voice can speak with wisdom, One heart can know what's true.
One life can make the difference, You see, it's up to you and me.
To get God's work done on Earth,
"if it's going to be, it will be up to YOU and ME!"
By DR. G. M. SINGH

Respected Sir, eMedinewS provides very valuable service to medical professional of country. It provides “Umid Se Duguna” – much more than you can imagine. Selection of practical topics with practical tips, lots of Update and much more in eMedinewS is impressive. I fear, in morning doctors will read eMedinewS first and news paper later. Regards: Dr Sanjay Pandya

For most non–critically ill hospitalized patients with diabetes, one should have a target blood sugar of <180 mg/dL. In non–critically ill hospitalized patients, lower blood glucose levels may decrease the risk of poor clinical outcomes, but also increase the risk of hypoglycemia. A reasonable sugar goal to avoid low blood sugar is to achieve fasting blood glucose levels no lower than 90 to 100 mg/dL.

Preventing a Peptic Ulcer
An ulcer is a breakdown in the lining of the stomach or the first part of the small intestine. A type of bacterial infection is the most frequent cause, but lifestyle factors may also raise the risk said Dr Aggarwal.
One may follow these preventive steps that may ward off a peptic ulcer:

Limit alcohol to no more than two drinks daily.

Stop smoking or chewing tobacco.

If you need to take painkillers, avoid anti–inflammatory drugs (NSAIDs) such as naproxen, ibuprofen or aspirin.

Consider, with your doctor’s approval, paracetamol instead.

Forthcoming Events

Launching of First Website on Kidney Diseases in Hindi www.kidneyinhindi.com by Dr Vidya Acharya
Date: 18 September 2010, Saturday Venue: Annual Conference of the Indian Society of Nephrology- Western Chapter, Daman

The 2nd eMedinewS – revisiting 2010 conference will be held at Maulana Azad Medical College, New Delhi on January 2, 2011. The event will have a day–long CME, Doctor of the Year awards, Cultural Hungama and Live Webcast. Suggestions are invited.

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